Coronary Sinus Lactate as Marker of Myocardial Ischemia in Cardiac Surgery: Correlation with Morbidity and Mortality after Cardiac Surgery / Lactatul din sinusul coronarian - marker al ischemiei miocardice în chirurgia cardiacă: corelaţii cu morbiditatea şi mortalitatea postoperatorie
Introduction. Perioperative myocardial injuries are one of the most frequent causes of morbidity and mortality after cardiac surgery, the most common etiology being the poor myocardial protection during aortic crossclamp. During aortic crossclamp progressive accumulation of lactate and intracellular acidosis are well-known phenomena, and are associated with alteration of myocardial contractile function. Our objective was to study the coronary sinus lactate levels as a predictor of postoperative hemodynamic outcome in open-heart surgical patients.
Material and methods. We performed a prospective clinical trial, including 142 adult patients with elective cardiac surgery. Anterograde cardioplegia was administered in 82 patients, retrograde cardioplegia in 60 (in 30 patients it was administrated intermittently and in 30 continuously). Blood was collected simultaneously from the aortic cardioplegic line (inflow) and from coronary sinus or the aortic root (outflow) before aortic crossclamp, after crossclamp at every 10 minutes and after crossclamp removal at 0 and 10 minutes. All patients were operated on cardiopulmonary bypass with cardiac arrest, using warm-blood cardioplegia for cardioprotection.
Results. Lactate levels showed increasing values during aortic crossclamp, and a rapid decline after crossclamp removal. The incidence of low cardiac output was significantly higher in patients with lactate levels that exceeded 4 mmol/L. In patients who died in the postoperative period, lactate level was even higher (5 mmol/L), with only a modest recovery after crossclamp removal.
Conclusion. Monitoring lactate level in coronary sinus blood is a reliable method and has a good prognostic value regarding postoperative morbidity and mortality in open heart surgery
1. Kapoor PM, Mandal B, Chowdhury UK, Singh S, Kiran U. Changes in myocardial lactate, pyruvate and lactate-pyruvate ratio during cardiopulmonary bypass for elective adult cardiac surgery: Early indicator of morbidity, J Anaesthesiol Clin Pharmacol. 2011; Apr; 27(2): 225-32. DOI: 10.4103/0970-9185.81819
2. Mentzer RM Jr. Myocardial protection in heart surgery. J Cardiovasc Pharmacol Ther. 2011 Sep- Dec;16(3-4):290-7. DOI: 10.1177/1074248411410318
3. Kinoshita T, Asai T. Preservation of myocardium during coronary artery bypass surgery. Curr Cardiol Rep. 2012 Aug;14(4):418-23. DOI: 10.1007/s11886-012-0271-0
4. Borowski A, Kurt M, Calvo S, Paprotony G, Godehardt E, et al. Metabolic Monitoring of Postischemic Myocardium during Intermittent Warm-Blood Cardioplegic Administration. Tex Heart Inst J. 2010;37(2):184-8.
5. Kumbhani DJ, Healey NA, Birjiniuk V, Crittenden MD, Treanor PR, et al. Intraoperative regional myocardial acidosis predicts the need for inotropic support in cardiac surgery. Am J Surg. 2004 Nov;188(5):474-80. DOI: 10.1016/j.amjsurg.2004.07.015
6. Healey CM, Kumbhani DJ, Healey NA, Crittenden MD, Gibson SF, Khuri SF. Impact of intraoperative myocardial tissue acidosis on postoperative adverse outcomes and cost of care for patients undergoing prolonged aortic clamping during cardiopulmonary bypass. Am J Surg. 2009 Feb;197(2):203-10. DOI: 10.1016/j. amjsurg.2008.01.023
7. Calafiore AM, Teodori G, Mezzetti A, Bosco G, Verna AM, Di Giammarco G, Lapenna D. Intermittent antegrade warm blood cardioplegia. Ann Thorac Surg. 1995 Feb;59(2):398-402. DOI: 10.1016/0003-4975(94)00843-V
8. Oliveira MS, Floriano EM, Mazin SC, Martinez EZ, Vicente WV, Peres LC, et al. Ischemic myocardial injuries after cardiac malformation repair in infants may be associated with oxidative stress mechanisms. Cardiovasc Pathol. 2011 Jan-Feb;20(1):e43-52. DOI: 10.1016/j.carpath.2010.01.012
9. Abah U, Roberts PG, Ishaq M, De Silva R. Is cold or warm blood cardioplegia superior for myocardial protection? Interact CardioVasc Thorac Surg. 2012;14(6):848-55. DOI: 10.1093/icvts/ivs069
10. Onorati F, Cristodoro L, Caroleo S, Esposito A, Amantea B, et al. Troponin I and Lactate From Coronary Sinus Predict Cardiac Complications After Myocardial Revascularization. Ann Thorac Surg. 2007 Mar;83:1016-23. DOI: 10.1016/j.athoracsur.2006.10.103
11. Shivanand P. A review on pathology of myocardial ischemia and various types of novel biomarkers. International Journal of Pharmaceutical Sciences Review and Research. 2010 Jun;2:35-9.
12. McDonnell B, Hearty S, O’Kennedy R. Cardiac biomarkers and the case for point/of/care testing. Clinical Biochemistry. 2009;42:549-61. DOI: 10.1016/j.clinbiochem. 2009.01.019
13. Heringlake M, Bahlmann L, Misfeld M, Poeling J, Leptien A, Kraatz E, et al. High myocardial lactate concentration is associated poor myocardial function prior to cardiopulmonary bypass. Minerva Anestesiol. 2005 Dec;71:775-83.
14. White HD. Pathobiology of Troponin Elevations.Do Elevations Occur With Myocardial Ischemia as Well as Necrosis? J Am Coll Cardiol. 2011;57(24):2406-8. DOI: 10.1016/j.jacc.2011.01.029
15. Khabbaz KR, Zankoul F, Warner KG. Intraoperative metabolic monitoring of the heart: online measurement of myocardial tissue pH. Ann Thorac Surg. 2001 Dec;72(Suppl):2227-34. DOI: 10.1016/S0003-4975(01)03284-2
16. Khuri SF, Healey NA, Hossain M, Birjiniuk V, Crittenden MD, et al. Intraoperative regional myocardial acidosis and reduction in long-term survival after cardiac surgery. J Thorac Cardiovasc Surg. 2005 Feb;129:372-81. DOI: 10.1016/j.jtcvs.2004.05.020
17. Habertheuer A, Kocher A, Laufer G, Andreas M, Szeto WY, et al. Cardioprotection: A Review of Current Practice in Global Ischemia and Future Translational Perspective. Review Article. BioMed Research International. 2014;Article ID 325725,11 pages.
18. Lutz J, Thürmel K, Heemann U. Anti-inflammatory treatment strategies for ischemia/reperfusion injury in transplantation. J Inflamm (Lond). 2010 May 28;7:27. DOI: 10.1186/1476-9255-7-27
19. Schotola H, Toischer K, Popov AF, Renner A, Schmitto JD, Gummert J, et al. Mild metabolic acidosis impairs the β-adrenergic response in isolated human failing myocardium. Crit Care. 2012 Aug 13;16(4):R153. DOI: 10.1186/cc11468
20. Sabatini S, Kurtzman NA. Bicarbonate Therapy in Severe Metabolic Acidosis. JASN. 2009 Apr;20(4):692-5. DOI: 10.1681/ASN.2007121329
22. Nicolini F, Beghi C, Muscari C, Agostinelli A, Maria Budillon A, Spaggiari I, et al. Review. Myocardial protection in adult cardiac surgery: current options and future challenges. Eur J Cardiothorac Surg. 2003 Dec;24(6):986-93. DOI: 10.1016/S1010-7940(03)00475-5
23. Flack JE 3rd, Cook JR, May SJ, Lemeshow S, Engelman RM, Rousou JA, et al. Does cardioplegia type affect outcome and survival in patients with advanced left ventricular dysfunction? Results from the CABG Patch Trial. Circulation. 2000 Nov 7;102(19 Suppl 3):III84-9. DOI: 10.1161/01.cir.102.suppl_3.iii-84